Television-supported self-help for problem drinkers: a randomized pragmatic trial

A systematic review and behaviour change technique analysis of remotely delivered alcohol and/or substance misuse interventions for adults

BACKGROUND

There has been a lack of systematic exploration of remotely delivered intervention content and their effectiveness for behaviour change outcomes. This review provides a synthesis of the behaviour change techniques (BCT) contained in remotely delivered alcohol and/or substance misuse approaches and their association with intervention promise.

METHODS

Searches in MEDLINE, Scopus, PsycINFO (ProQuest), and the Cochrane Library, included studies reporting remote interventions focusing on alcohol and/or substance misuse among adults, with a primary behaviour change outcome (e.g., alcohol levels consumed). Assessment of risk of bias, study promise, and BCT coding was conducted. Synthesis focussed on the association of BCTs with intervention effectiveness using promise ratios.

RESULTS

Studies targeted alcohol misuse (52 studies) or substance misuse (10 studies), with predominantly randomised controlled trial designs and asynchronous digital approaches. For alcohol misuse studies, 16 were very promising, 17 were quite promising, and 13 were not promising. Of the 36 eligible BCTs, 28 showed potential promise, with seven of these only appearing in very or quite promising studies. Particularly promising BCTs were 'Avoidance/reducing exposure to cues for behaviour', 'Pros and cons' and 'Self-monitoring of behaviour'. For substance misuse studies, three were very promising and six were quite promising, with all 12 BCTs showing potential promise.

CONCLUSIONS

This review showed remotely delivered alcohol and substance misuse interventions can be effective and highlighted a range of BCTs that showed promise for improving services. However, concerns with risk of bias and the potential of promise ratios to inflate effectiveness warrant caution in interpreting the evidence.

A 9-month follow-up of a 3-month web-based alcohol treatment program using intensive asynchronous therapeutic support

BACKGROUND

Web-based alcohol interventions have demonstrated efficacy in randomized controlled trials. However, most studies have involved self-help interventions without therapeutic support.

OBJECTIVES

To examine the results of a 3-month web-based alcohol treatment program using intensive, asynchronous (non-simultaneous) therapeutic support ( www.alcoholdebaas.nl ) at 9-month follow-up assessment.

METHODS

This study reports the follow-up results of 144 problem drinking participants who received a web-based alcohol treatment program. We investigated whether the intervention effects at treatment completion (3 months) continued to exist at 6 and 9 months of follow-up. The primary outcome measure was weekly alcohol consumption. Repeated measures analysis with a mixed model approach was used to address loss to follow-up.

RESULTS

Weekly alcohol consumption significantly improved between baseline and 9 months (F(1,74) = 85.6, p < 0.001). Post-hoc tests revealed that the reduction occurred during the first 3 months (from 39.9-11.4 standard units a week). Although alcohol consumption had risen to 19.5 units per week at 9 months, it still decreased by more than 20 units compared to baseline drinking. Significant improvements with medium to large effect sizes were found on the secondary outcomes (depression, general health, and quality of life) at 9 months.

CONCLUSION

The web-based alcohol treatment with intensive asynchronous therapeutic support has been shown to be effective in reducing alcohol consumption and improving health status at post treatment assessments. The present study showed that most of these improvements were sustained after 9 months. Despite the lack of a control group and the high dropout rate, our findings suggest that web-based treatment can achieve relevant health gains in the long term.

Mental Vitality @ Work--a workers' health surveillance mental module for nurses and allied health care professionals: process evaluation of a randomized controlled trial

OBJECTIVE

To evaluate the process of workers' health surveillance (WHS) targeting work functioning and mental health of health care professionals, alongside a randomized controlled trial comparing two strategies.

METHODS

Nurses and allied health care professionals working in one hospital were invited. Process indicators were assessed using methods such as questionnaires and track-and-trace data.

RESULTS

All participants (32%; N = 369) received screening and personalized feedback. In group 1, 41% went to a preventive consultation with their occupational physician. Protocol adherence of participating occupational physicians (n = 5) was high. They regarded the WHS mental module to be meaningful. In group 2, 16% logged into an e-mental health intervention. Most participants would appreciate a future offer of the WHS.

CONCLUSIONS

The WHS mental module was well received and fitted in the occupational health service activities. Nevertheless, response and compliance should be improved.

Building the first step: a review of low-intensity interventions for stepped care

Within the last 30 years, a substantial number of interventions for alcohol use disorders (AUDs) have received empirical support. Nevertheless, fewer than 25% of individuals with alcohol-related problems access these interventions. If several intensive psychosocial treatments are relatively effective, but most individuals in need do not access them, it seems logical to place a priority on developing more engaging interventions. Accordingly, after briefly describing findings about barriers to help-seeking, we focus on identifying an array of innovative and effective low-intensity intervention strategies, including telephone, computer-based, and Internet-based interventions, that surmount these barriers and are suitable for use within a stepped-care model. We conclude that these interventions attract individuals who would otherwise not seek help, that they can benefit individuals who misuse alcohol and those with more severe AUDs, and that they can facilitate subsequent help-seeking when needed. We note that these types of low-intensity interventions are flexible and can be tailored to address many of the perceived barriers that hinder individuals with alcohol misuse or AUDs from obtaining timely help. We also describe key areas of further research, such as identifying the mechanisms that underlie stepped-care interventions and finding out how to structure these interventions to best initiate a program of stepped care.

Attrition in web-based treatment for problem drinkers

Background

Web-based interventions for problem drinking are effective but characterized by high rates of attrition. There is a need to better understand attrition rates in order to improve the completion rates and the success of Web-based treatment programs.

Objective

The objectives of our study were to (1) examine attrition prevalence and pretreatment predictors of attrition in a sample of open-access users of a Web-based program for problem drinkers, and (2) to further explore attrition data from our randomized controlled trial (RCT) of the Web-based program.

Methods

Attrition data from two groups of Dutch-speaking problem drinkers were collected: (1) open-access participants enrolled in the program in 2009 (n = 885), and (2) RCT participants (n = 156). Participants were classified as noncompleters if they did not complete all 12 treatment sessions (9 assignments and 3 assessments). In both samples we assessed prevalence of attrition and pretreatment predictors of treatment completion. Logistic regression analysis was used to explore predictors of treatment completion. In the RCT sample, we additionally measured reasons for noncompletion and participants’ suggestions to enhance treatment adherence. The qualitative data were analyzed using thematic analysis.

Results

The open-access and RCT group differed significantly in the percentage of treatment completers (273/780, 35.0% vs 65/144, 45%, χ²₁ = 5.4, P = .02). Logistic regression analysis revealed a significant contribution of treatment readiness, gender, education level, age, baseline alcohol consumption, and readiness to change to predict treatment completion. The key reasons for noncompletion were personal reasons, dissatisfaction with the intervention, and satisfaction with their own improvement. The main suggestions for boosting strategies involved email notification and more flexibility in the intervention.

Conclusions

The challenge of Web-based alcohol treatment programs no longer seems to be their effectiveness but keeping participants involved until the end of the treatment program. Further research should investigate whether the suggested strategies to improve adherence decrease attrition rates in Web-based interventions. If we can succeed in improving attrition rates, the success of Web-based alcohol interventions will also improve and, as a consequence, their public health impact will increase.

Trial

International Standard Randomized Controlled Trial Number (ISRCTN): 39104853; http://www.controlled-trials.com/ISRCTN39104853 (Archived by WebCite at http://www.webcitation.org/63IKDul1T)

Telemedicine interventions for substance-use disorder: a literature review

A literature review was conducted to identify research into multiple-contact (i.e. extended) telemedicine interventions for substance-use disorder. The goals were: (1) to describe the methodology used to evaluate telemedicine interventions; (2) to identify the range of interventions which have been formally evaluated; and (3) to summarize the findings. Fourteen databases and Google Scholar were searched, as well as bibliographies of relevant papers and online conference abstracts. There were 50 studies which met the inclusion criteria, of which 50% were randomized controlled trials. The studies most frequently reported the effect on substance use and 61% of those findings fully supported telemedicine interventions. Although the studies reported persistent challenges in sustaining participation, 76% of the studies reporting on satisfaction indicated that participants were enthusiastic supporters of telemedicine. Only 30% of reviewed studies addressed the effect on resource utilization. The majority of studies reported evidence of clinical effectiveness, which justifies continued research in the field.

Effectiveness of E-self-help interventions for curbing adult problem drinking: a meta-analysis

Background

Self-help interventions without professional contact to curb adult problem drinking in the community are increasingly being delivered via the Internet.

Objective

The objective of this meta-analysis was to assess the overall effectiveness of these eHealth interventions.

Methods

In all, 9 randomized controlled trials (RCTs), all from high-income countries, with 9 comparison conditions and a total of 1553 participants, were identified, and their combined effectiveness in reducing alcohol consumption was evaluated by means of a meta-analysis.

Results

An overall medium effect size (g = 0.44, 95% CI 0.17-0.71, random effect model) was found for the 9 studies, all of which compared no-contact interventions to control conditions. The medium effect was maintained (g = 0.39; 95% CI 0.23-0.57, random effect model) after exclusion of two outliers. Type of control group, treatment location, type of analysis, and sample size did not have differential impacts on treatment outcome. A significant difference (P = .04) emerged between single-session personalized normative feedback interventions (g = 0.27, 95% CI 0.11-0.43) and more extended e- self-help (g = 0.61, 95% CI 0.33-0.90).

Conclusion

E-self-help interventions without professional contact are effective in curbing adult problem drinking in high-income countries. In view of the easy scalability and low dissemination costs of such interventions, we recommend exploration of whether these could broaden the scope of effective public health interventions in low- and middle-income countries as well.

The Mental Vitality @ Work study: design of a randomized controlled trial on the effect of a workers' health surveillance mental module for nurses and allied health professionals

BACKGROUND

Employees in health care service are at high risk for developing mental health complaints. The effects of mental health complaints on work can have serious consequences for the quality of care provided by these workers. To help health service workers remain healthy and productive, preventive actions are necessary. A Workers' Health Surveillance (WHS) mental module may be an effective strategy to monitor and promote good (mental) health and work performance. The objective of this paper is to describe the design of a three arm cluster randomized controlled trial on the effectiveness of a WHS mental module for nurses and allied health professionals. Two strategies for this WHS mental module will be compared along with data from a control group. Additionally, the cost effectiveness of the approaches will be evaluated from a societal perspective.

METHODS

The study is designed as a cluster randomized controlled trial consisting of three arms (two intervention groups, 1 control group) with randomization at ward level. The study population consists of 86 departments in one Dutch academic medical center with a total of 1731 nurses and allied health professionals. At baseline, after three months and after six months of follow-up, outcomes will be assessed by online questionnaires. In both intervention arms, participants will complete a screening to detect problems in mental health and work functioning and receive feedback on their screening results. In cases of impairments in mental health or work functioning in the first intervention arm, a consultation with an occupational physician will be offered. The second intervention arm offers a choice of self-help e-mental health interventions, which will be tailored based on each individual's mental health state and work functioning. The primary outcomes will be help-seeking behavior and work functioning. Secondary outcomes will be mental health and wellbeing. Furthermore, cost-effectiveness in both intervention arms will be assessed, and a process evaluation will be performed.

DISCUSSION

When it is proven effective compared to a control group, a WHS mental module for nurses and allied health professionals could be implemented and used on a regular basis by occupational health services in hospitals to improve employees' mental health and work functioning.

TRIAL REGISTRATION

NTR2786.

Content and functionality of alcohol and other drug websites: results of an online survey

BACKGROUND

There is a growing trend for individuals to seek health information from online sources. Alcohol and other drug (AOD) use is a significant health problem worldwide, but access and use of AOD websites is poorly understood.

OBJECTIVE

To investigate content and functionality preferences for AOD and other health websites.

METHODS

An anonymous online survey examined general Internet and AOD-specific usage and search behaviors, valued features of AOD and health-related websites (general and interactive website features), indicators of website trustworthiness, valued AOD website tools or functions, and treatment modality preferences.

RESULTS

Surveys were obtained from 1214 drug (n = 766) and alcohol website users (n = 448) (mean age 26.2 years, range 16-70). There were no significant differences between alcohol and drug groups on demographic variables, Internet usage, indicators of website trustworthiness, or on preferences for AOD website functionality. A robust website design/navigation, open access, and validated content provision were highly valued by both groups. While attractiveness and pictures or graphics were also valued, high-cost features (videos, animations, games) were minority preferences. Almost half of respondents in both groups were unable to readily access the information they sought. Alcohol website users placed greater importance on several AOD website tools and functions than did those accessing other drug websites: online screening tools (χ²(2) = 15.8, P < .001, n = 985); prevention programs (χ²(2) = 27.5, P < .001, n = 981); tracking functions (χ²(2) = 11.5, P = .003, n = 983); self help treatment programs (χ²(2) = 8.3, P = .02, n = 984); downloadable fact sheets for friends (χ²(2) = 11.6, P = .003, n = 981); or family (χ²(2) = 12.7, P = .002, n = 983). The most preferred online treatment option for both the user groups was an Internet site with email therapist support. Explorations of demographic differences were also performed. While gender did not affect survey responses, younger respondents were more likely to value interactive and social networking features, whereas downloading of credible information was most highly valued by older respondents.

CONCLUSIONS

Significant deficiencies in the provision of accessible information on AOD websites were identified, an important problem since information seeking was the most common reason for accessing these websites, and, therefore, may be a key avenue for engaging website users in behaviour change. The few differences between AOD website users suggested that both types of websites may have similar features, although alcohol website users may more readily be engaged in screening, prevention and self-help programs, tracking change, and may value fact sheets more highly. While the sociodemographic differences require replication and clarification, these differences support the notion that the design and features of AOD websites should target specific audiences to have maximal impact.